Coping: neither good, nor bad, but “it depends”

Coping is a concept we often use in chronic pain management.

Our aim as clinicians is to help people with chronic pain cope with their pain so they can do more of what is important to them.

Most of us know that coping mediates between the individual and whatever challenge he or she is facing. Coping reduces the impact of the challenge. Most of us also know that there are a range of coping strategies that people can use – and most of us have learned that coping strategies can be “adaptive” or “maladaptive”, “active” or “passive”, “approach” or “avoidant”. Unfortunately, much of the time this dichotomous taxonomy turns into a “do this” and “don’t do that” list of good or bad strategies.

What this means is that strategies such as resting and delegating are both considered “passive”, therefore “avoidant” and consequently are “maladaptive” – and as clinicians we tell people “don’t do that” because they feature on our list of bad strategies.

I thought this too until I started researching the ways that people who cope well with pain deal with pain in their lives.

I thought, when I began my study, that I would find a neat list of strategies that people used, and that these would fall into the “adaptive”, “active” and “approach” categories of coping.

They don’t. Nope, people who live well with their chronic pain just do not do what I expected.

People who cope well use “anything and everything”, or as my participants put it “anything that works”.

Back to the drawing board you’d think! But I spent a long time listening to the ways people solve the problem of how to get on with life despite chronic pain, and something struck me: when a person talked about using a coping strategy, any coping strategy, it wasn’t all about the pain. In fact, pain rarely got a mention. What did get discussed was how, by using “anything that works”, people got to do what they valued in their lives. In other words, they judged whether a strategy worked by how well it helped them do what they prioritised.

In technical terms this is called functional contextualism – evaluating an action in the context in which it is used. Coping strategies cannot, within this framework, be evaluated in isolation from the where and why of its use.

Let me give you a brief example: Resting is usually thought of as an unhelpful way to manage chronic pain. It’s thought to lead to deconditioning, avoidance and fear of pain, and loss of good things in life. Yet, what if, by resting in the afternoon, a person is able to go out to celebrate her 21st birthday? In the context of a person having a 21st birthday party, resting in the afternoon enables her to do something she values.

If resting is the only coping strategy this person has, or if resting is the primary way this person copes with painful flare-ups, and if resting also interferes with this person’s overall ability to live independently, then perhaps resting is not useful for her all the time. On the other hand, if she has many different ways to deal with her pain, and she also uses planning and medication and exercise, and if she’s able to live independently and do the things she wants to be able to do, resting has usefulness.

That’s functional contextualism, and that’s how people who cope well with pain use their coping strategies.

What does this mean for us as clinicians?

It means we need to take time to understand why, when, where and how the people we work with do the things that are important to them. If they don’t know how to do what’s important, if they only have a few coping strategies to choose from, and if they’re distressed because their one strategy gets in the way of things they value, then and only then are their coping strategies unhelpful. It also means that using a coping strategies inventory might not be a good way to decide if a person needs help developing coping strategies. We might instead choose to use something like the Chronic Pain Coping Inventory as a way to identify the range of strategies an individual knows about, rather than whether the things they use are “passive” or “active”. To measure whether their strategies are working for them – well my guess would be to use something like the Canadian Occupational Performance Measure, or a disability outcome measure.

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9 comments

That’s really interesting and made me think about a physio colleague and her thoughts about assistive devices. As someone with long experience in pain management she recalled the days when Pain Management Programmes were much more strictly behavioural and viewed devices as mal adaptive behaviours. Her view was that it didn’t really matter so long as folk were using them to achieve meaningful activities.

I’m not sure – I think the answer is “it depends” LOL
If, by using adaptive equipment, the person is enabled and isn’t avoiding the experience of pain (ie is willing to experience pain if it means he or she can do what’s important in their life), then I don’t have a problem with equipment. there are drawbacks though, and one of them is that equipment gets in the way of doing many things. If you can’t sit in a “normal” chair, or can’t walk over rough ground without a walking stick because you’re afraid of jarring your back, then maybe that strategy is not working as well as using another approach, or having more than one strategy to use.
I’ll post again next week, but I found that people who cope well use “flexible persistence” to get on with life – this means they “find a way” (any way) to do what’s important to them, and most importantly, they were mindful (nonjudgementally aware) of their pain. They weren’t trying to avoid it, rather they were trying to manage the energy demands associated with dealing with it.
Thanks for taking the time to comment!

Find strategies that give you some respite (a break from the incessant job of dealing with this situation) when you need it, find strategies that help you calm down the wound-up cranky nervous systems, and find ways to challenge your current abilities.
Flexible persistence makes a lot of sense!

I think this is exactly right. I am a patient, and I had an experience similar to what Derek described. For a couple of years I was under care of doctors who said that I should stop all physical therapy, that this is too passive and will prevent me from coping. Once I stopped, I struggled to keep up with my exercise program, and eventually my pain got so severe that I had to stop some of my favourite physical activities, because they were causing intolerable pain. I seemed to be on a spiral when none of the coping strategies suggested by the pain program worked for me, and I kept getting more and more disabled, yet the doctors insisted that if only I followed their advice better/more consistently, I will get better “in another 6 months”, never mind that I have shown no improvement in the last 24. When I pointed out that I was coping better when I was getting regular physical therapy, the answer was “but it has not removed your pain, therefore it is not useful in the long term”.

Eventually I found a physical therapist who specialized in chronic pain patients but used different approach. Her philosophy was that she was there to help me do more activities that I enjoyed. She did a lot of manipulation and other “hands on” interventions, but whenever we discussed my progress and next steps, the focus was on my ability to get things done in between the appointments, and on building up my favorite physical activities.

When I started with this treatment, I encountered a lot of resistance from my chronic pain doctors. I have two letters from NHS consultants to my GP on file saying that I have taken up treatment that is “too passive” and “proven ineffective”. Yet, after 3 years, my pain is now much better managed.

Physical therapy didn’t “cure” my pain, I still experience a fair amount of it. But I can do things that I could not even contemplate a few years ago. It used to be “if I do X, I will get pain and fatigue that will prevent other things in the next 7 days”. Now it is “If I do X, I should schedule a physio appointment in the next day or two, so that I can do Y and Z tomorrow”.

In my case, I found the “active” vs. “passive” labels unhelpful, because they carried a lot of judgment and hindered my ability to figure out things that worked. It was really difficult to persist in trying out different things when doctors labeled them passive and/or maladaptive, despite what I felt was working (or not). It was strange for the program to be labeled “passive”, too, when as part of it I was engaging in graded exercise and planning out activity goals based on what I valued, but this is what seemed to happen, with several different consultants, too. I think the post captured what I found about coping really well, and also what worked for me in the end.

And, by the way, saying things like “intolerable pain” is just a shorthand for “the level of pain that will make difficult to concentrate and/or sleep, and therefore make me more tired and make it difficult to get other things done”. It is just really difficult to avoid talking as pain being a problem, but it’s exactly as the other comment said – pain coping with it makes too large a demand on my energy. I wish I had a way to talk that is both brief and makes it clear how I think, but it is difficult, I find.

Good on you Mary, you’ve done a lot of work to find ways that help you.
The way I’d approach this kind of situation in a clinical setting would be to ask you what the good and not-so-good things are about how you’re handling your situation. There are always both good and not-so-good aspects of any way to deal with a situation, but the judgement of this is individual.

I’d ask about what might happen if, for example, your physiotherapist retired or stopped providing that service – are there benefits in learning how to handle this yourself? Does it take time out of your life that you’d rather spend doing something else? Do you have options you can use when/if your therapist isn’t available or you’re on holiday and can’t get in to see him/her?

The ultimate judgement is whether you have options to choose from, or do you get stuck and end up using only one way of coping, because if you only have one choice, you’ll end up getting either stuck or unable to do the things you value.

I cannot possibly answer these questions – and neither should any other clinician try to on behalf of a patient/client. They’re the sort of questions that we all deal with every day when we prioritise the things we want to do each day – every one of us, whether we have pain or not.

Why then, would we think that people with pain might want to do anything different?

In the context of broader health provision policy I can understand some of the caution clinicians have for ongoing passive therapies. it’s expensive, and when there are alternatives it can be a difficult choice to make: do we fund a person to have ongoing passive therapy, or do we allocate that funding to help them learn new ways of coping so they don’t have to keep having treatment, then we can afford to help other people, and so on.
In the context of my personal choices, however, I know I’d like to be able to make a choice rather than being dictated to. I’d pay for occasional passive treatments from time to time if I could afford them, if they reduced my pain, if they didn’t get in the way of doing other important stuff, and if I had a good relationship with the person giving them. But these criteria reflect my values, and I wouldn’t want to impose them on anyone else.

I think these are all very important questions. I even understand the economic argument. In fact, I paid for that (successful) physical therapist myself. What I found really difficult through that whole process was that my pain doctors were not willing to have such a value-based discussion as you describe. The time spent on appointments, the money involved, the potential risks involved in trying practitioners outside the system are considerable, and these decisions are so much more difficult when one is struggling with pain. What I wanted, more than anything else, is the ability to manage my treatment in an integrated way, even if I had to pay for part of it myself. But it seemed that the “passive” vs “active/self-management” overshadowed everything else.

I also found that while the questions like “what would happen if your practitioner left” are importnat, but sometimes also confuse real issue. Yes, I would like to completely self-manage, ideally. In fact, this is exactly what happened to me last year – my original physical therapist left permanently. Since I already was feeling much better, I though, “OK, can I try to self-manage again?”. The answer was, ultimately I could not. It’s not that she was my only coping strategy, and I had stretches etc. that she and I worked out to cover travel etc. when she was unavailable. But these strategies did not work in a long term, and after about 3 months I started significantly deteriorating again. My solution was to try out a few more practitioners until I found one with a similar philosophy and who achieved similar results with her hands-on work.

I am not saying that you use these questions wrongly with your patients, but this was another one pushed at me as part of CBT pain management component – “it is a bad idea to be dependent on a practitioner, because if they leave, you won’t be able to cope, and this is bad for you. If you could cope by yourself, that would be better”. I found that the true answer for me is, yes, I am not able to cope by myself, but I can cope with some support and I know what to look for in a replacement. So, as your original post said, it’s not good or bad in itself, it’s all in the context of what the options are and the ability to find alternatives.

I hope you get your dissertation published – I wish more of this stuff would make it into the research literature.

Good points Mary, I don’t think many medical practitioners (and maybe other forms of clinician as well) have been taught that in the end, it’s the person with the pain who will decide how he or she wants to manage their situation. I’ve adopted the motivational interviewing approach – because I found that people will do exactly what they want to do, irrespective of any sort of persuasion or cajoling or threatening. It’s more respectful to help the person decide whether the costs outweigh the benefits, but more than that, any alternative just doesn’t work – and you’ve described exactly that! Despite not having support to go to a hands-on therapist, you went anyway! And now you have a memory of people who didn’t listen to you, and didn’t respect your autonomy. My bet is that those people probably found the interactions negative as well, so it’s just a waste of energy to attempt to dictate what is, or isn’t, good coping.
Wouldn’t it be wonderful if, when anyone goes to a health professional, that person would take the time to find out why you do what you do, help you evaluate it against your values, and helped generate options if, as often happens, one or more of the ways you cope gets stymied. Then at least you’d feel you had something of value from the encounter, you might open up some new options, and when the going gets tough, you have a relationship you can count on.

It’s so good to have you back!!! I was wondering why I hadn’t received any of your blog posts for quite a while … now I know why! Hope the writing up is successful 🙂

I myself am starting to have a think about a topic for my own PhD and am starting to delve into focused attention training … reading your post emphasises the importance of context to any situation …. and the geek in me just gets terribly excited about the possibilities!

Was wondering whether you have a copy of the 2013 article you referenced in this post … if you do, do you think you could send me a copy?